It is clear that a new look at the Affordable Care Act is in the pipeline. Although President-elect Trump campaigned on a platform to repeal or replace it, scrapping it entirely does not seem likely.
Aspects of the ACA have been nightmarish for physicians and patients alike. For instance, many solo physicians (myself included) have struggled with needless regulations and requirements that detract time and attention from the one thing that physicians so desperately need: time with patients. In an era of increased bureaucracy and time constraints, many features of the ACA precluded doctors from focusing in on why their patients were in the office. Instead, physicians are required to ask questions and document aspects of the exam that are not relevant but instead forced on them by the ACA. This facet of the ACA needs to be changed.
There are many regulations that physicians struggle with and many metrics that are not easily gathered by physicians who are in small practices where they actually know their patients, understand their issues, and are active in their communities. These metrics are forcing physicians to sell practices to larger groups or to hospitals so that they can simply become employees who no longer have to deal with the burden of regulations that its own authors concede they do not fully understand.
As this occurs, the impact on jobs is significant. Many of my colleagues employ between 5-15 people in their office. These tend to be good jobs that pay well and are attached to benefits. As small practices disappear from the landscape of American medicine, so too do these jobs. Employees in small practices have opportunities to advance as they learn new skills and many will obtain degrees that will become valuable as they ascend. The ACA has done a great deal to threaten these small practices and the jobs they bring. What happens when these practices are gobbled up by larger entities? Several things: basic services such as patient care are sourced to lower wage workers, patients no longer have a direct relationship with their physicians and, in many cases, care is delegated to less expensive providers. In some cases, this means outsourcing to distant places. Replacing parts of the ACA that are pressuring medicine to become less patient-centric will result in better patient care and more stable employment in healthcare.
Not all of the ACA is bad: the ability of people with pre-existing conditions to get insurance is critical but needs to be accompanied by balancing the risk pools (as was originally suggested by the authors of the ACA). This can be accomplished by negotiating these risk pools so that they have broader, more age-diverse populations. The ACA should keep features that allow children to say on their parents’ policies until they are 26 and should work with states to reform the various exchanges. Perhaps a system that provides care but has limits on liability could be enacted much like the system that is used by the VA (which although it has its issues largely delivers efficient healthcare to many veterans). Perhaps allowing exchanges to compete across state lines and offering an age adjusted version of Medicare to compete with the exchanges would allow some competition.
Market based health care reform, in conjunction with the recognition that the system we had before the ACA is not sustainable, could bring us a system that allows people to choose their doctors and their insurance. Mandating that each person purchase a policy that in many cases they can not afford will not be a viable alternative. There are many aspects of the ACA that need to be fixed and we have an opportunity to do this in a manner that could be sustainable and be a source of jobs. Unlike the discussion that occurred prior to passage, we should have a reformation that is good for physicians and patients alike.
Dr. Kenneth Beer is a board certified dermatologist and dermatopathologist in West Palm Beach, Florida.
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